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Published byMorris Allen Modified over 9 years ago
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Atrial Fibrillation
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Outline Epidemiology Signs and Symptoms Etiology Differential Diagnosis Diagnostic Tests Classification Management
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Epidemiology Most frequently diagnosed arrhythmia Affects 2.3 million people in the US Affects 1/136 people in the US –Columbus population 769,360 (2009) Would expect to see 5600 pts/year! Incidence increases with age
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Signs and Symptoms Palpitations Weakness Dizziness Reduced exercise capacity Dyspnea Asymptomatic
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Etiology/Risk Factors Structural heart disease Chronic lung disease Pneumonia Hyperthyroidism Alcohol use Pulmonary embolism HTN Pericarditis MI is a very rare cause of Afib! Think twice before doing a ROMI Key Point
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Differential Diagnosis Narrow Complex Tachycardias –Atrial Fibrillation –Atrial Flutter –AVNRT –AVRT –Atrial tachycardia –Sinus tachycardia –Multifocal atrial tachycardia SVT is a category, not a diagnosis!
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Classification Paroxysmal: terminates in < 7 days Persistent: fails to terminate within 7 days Permanent: > 1 year Lone: Individuals without structural heart disease, < 60 yrs old
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Diagnostic Testing: EKG Narrow Complex Irregularly Irregular Rapid Ventricular Rate
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Diagnostic Testing: TTE To assess for structural heart disease –EF –Wall motion –Dilation/Hypertrophy –Size of right and left atrium –Valvular disease –Pericardial disease
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Chest X-Ray Look for emphasema/COPD Cardiac borders Pneumonia Rush Center for Congenital and Structural Heart Disease
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Management Rate Control Rhythm Control Anticoagulation Unstable patients
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Rate Control Why is rate control important? –Ischemia, MI, hypotension can occur –Long term: Cardiomyopathy Goals –Rest HR < 80 bpm –24 Hour (Tele/Holter) < 100 bpm average –HR < 110 in 6 minute walk Key Point
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Rate Control (con’t) Medications –Metoprolol / Esmolol: IV or Oral –Diltiazem: IV or Oral –Verapamil: Oral Only –Digoxin: Patients with hypotension –Amiodarone: Also for rhythm control
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Rhythm Control Indications –Symptoms of a-fib persistent –To avoid long term anticoagulation –Bleeding risk –Personal preferenance
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Rhythm Control (con’t) Synchronized DC cardioversion –Emergencies/Hemodynamic instability –Greater efficacy than medications Pharmacologic cardioversion –If AF < 7days – dofetilide, flecainide, ibutilide, propaferone or amiodarone –If AF > 7 day – dofetilide or amiodarone
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Rate or Rhythm Control? Affirm Study: Rate versus rhythm control –No difference in incidence of stroke –Trend towards lower mortality in the rate control group –See article –This is STILL a controversial topic!
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Anticoagulation and Cardioversion Afib < 48 hours: –Cardioversion (CV) –No anticoagulation indicated Afib > 48 hours: –Anticoagulate for 3-4 weeks before CV –OR get TEE –Anticoagulate for 1 month after CV
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Anticoagulation – Long Term Risk of CVA determined by CHADS2 score (CHF, HTN, >75, DM, Previous CVA x 2) ScoreAnnual Stroke Risk % 01.9 12.8 24.0 35.9 48.5 512.5 618.2 Key Points Most patients, can wait 48 hours before starting 0-1 probably don’t need anticoagulation 5-6 should be bridged with heparin/LMWH
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Management – Unstable Unstable: A-fib associated with Hypotension Synchronized electric Cardioversion immediately Key Point
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Key Points MI is a rare CAUSE of a-fib Rate control must be achieved during exercise, not just at rest Not every patients needs to bridge with heparin Unstable patients should immediately be cardioverted
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